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LETTER TO THE EDITOR

The Laryngeal Mask Airway for Airway Management During Percutaneous Tracheostomy: Everything Should Be Made as Simple as Possible but Not Simpler

Department of Anesthesiology; The University of Texas Medical School at Houston; Houston, Texas; carin.a.hagberg{at}uth.tmc.edu (Hagberg) Department of Surgery; School of Medicine, University of Pisa; Pisa, Italy (Cattano) Department of Anesthesiology; School of Medicine, Washington University of St. Louis; St. Louis, Missouri (Cattano)

In Response:

We appreciate Drs. Beiderlinden and Eikermann’s (1) shared interest in airway management during percutaneous tracheostomy (2). They remind us that percutaneous tracheostomy is not without risk, and that a laryngeal mask airway (LMA) does not protect against aspiration. Their point is well taken. Nonetheless, these procedures traditionally entail removal of the endotracheal tube. The cuff is deflated and the endotracheal tube is retracted to a position above the cricoid cartilage. Thus the seal is lost and the patient is at risk of aspiration. We recommend that patients undergoing percutaneous tracheostomy procedures be fasted for at least 4 h before the procedure, no matter what airway device is used. If there is concern about aspiration, the ProSeal-LMA (double-lumen LMA) provides a better seal than the traditional LMA and allows suctioning of the stomach contents (3).

If the patient has a history of, or has physical features of, a difficult airway, we recommend that an endotracheal tube be used rather than a LMA, with care taken to avoid endotracheal tube cuff puncture and accidental extubation. We suggest the use of an airway exchange catheter when an endotracheal tube is used to facilitate reintubation, if necessary. Although posterior wall bleeding rarely occurs with continuous fiberoptic viewing (4) (Griggs technique is superior to Ciaglia technique in preventing posterior wall lesions), an endotracheal tube can be reinserted either through the LMA or over an exchange catheter in order to bridge the defect and minimize hemorrhage into the trachea and lungs (5).

The literature supports our recommendation for using a LMA for these procedures (6,7). Despite the level of experience of the anesthesiologist, the LMA offers several advantages, including improved viewing for these procedures and serving as a reliable device for ventilation and reintubation, if necessary.

REFERENCES

1. Beiderlinden M, Eikermann M. LMA for airway management during percutaneous tracheostomy: everything should be made as simple as possible but not simpler. Anesth Analg 2006;104:743–4.
2. Cattano D, Abramson S, Buzzigoli S, et al. The use of the laryngeal mask airway during guidewire dilating forceps tracheostomy. Anesth Analg 2006;103:453–7.[Abstract/Free Full Text]
3. Cook TM, Taylor M, McKinstry C, et al. Use of the ProSeal laryngeal mask airway to initiate ventilation during intensive care and subsequent percutaneous tracheostomy. Anesth Analg 2003;97:848–50.[Abstract/Free Full Text]
4. Kaiser E, Cantais E, Goutorbe P, et al. Prospective randomized comparison of progressive dilational vs forceps dilational percutaneous tracheostomy. Anaesth Intensive Care 2006;34:51–4.[Web of Science][Medline]
5. Higgs A, Clark E, Premraj K. Low-skill fibreoptic intubation: use of the Aintree catheter with the classic LMA. Anaesthesia 2005;60:915–20.[Web of Science][Medline]
6. Dexter TJ. The laryngeal mask airway: a method to improve visualization of the trachea and larynx during fiberoptic assisted percutaneous tracheostomy. Anaesth Intensive Care 1994;22:35–9.[Web of Science][Medline]
7. Sustic A, Zupan Z, Antoncic I. Ultrasound-guided percutaneous dilatational tracheostomy with laryngeal mask airway control in a morbidly obese patient. J Clin Anesth 2004;16:121–3.[Web of Science][Medline]

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